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Advanced Health Assessment

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Title: Advanced Health Assessment


1
Advanced Health Assessment
  • Heather Hull, ARNP, PNP
  • Lesson 1

2
Welcome
  • This theory course has been previously offered
    both in traditional classroom interactive
    television formats..
  • The theory course is now being offered in a web
    based format.
  • This web based course is accompanied by a lab
    section, which is offered on the campus site.

3
New Technology
  • Course materials are offered online
  • Lecture notes outlines
  • PowerPoint outlines
  • CD-ROM lecture presentations with video streaming

4
Questions?
  • Contact me numbers addresses in syllabus
    Course Description Faculty
  • Discussion board will also be used for
    communication
  • I will return your calls messages ASAP
  • Scheduled office hours vary each semester posted
    in the Faculty section

5
Graduate Program Questions
  • Contact Graduate Program Secretary
  • Lori Griswold
  • Her contact numbers are listed in the syllabus,
    Faculty section

6
Class Schedule
  • The course is designed for one semester (8 or 16
    weeks)
  • Sixteen lessons
  • Lesson and lab sequence is concurrent
  • Lab schedules are individual for each campus site

7
University Sites
  • The class originates from Wichita State
    University
  • School of Nursing
  • Media Resource Center

8
Web Address
  • http//nursing.twsu.edu/advhealth
  • Course Home
  • Overview
  • Discussion
  • Resources
  • Lessons
  • Instructor

9
Major University Sites
  • Wichita State University (WSU)
  • Kansas University Medical Center (KUMC)
  • Fort Hays State University (FHSU)
  • Pittsburg State University (PSU)

10
Exams
  • Two multiple choice exams
  • Mid-term
  • Final
  • Scheduled proctored at each site

11
Exams Material Covered
  • Mid-Term Material discussed during first part of
    course
  • Final Material discussed during second part of
    course not comprehensive exam for all course
    material

12
Advanced Health Assessment Theory Course 2
Credit Hours
  • The focus of theory course over-all aspects of
    health assessment, with emphasis on
    differentiating abnormal from normal findings,
    common differential diagnosis
  • We will be looking for Horses not Zebras of
    differential diagnosis

13
Advanced Health Assessment Lab Course 1 Credit
Hour
  • Lab course is complimentary to theory course.
  • Focus is more on technical aspects of conducting
    complete health assessments

14
Major Course Objectives Assessment Across the
Lifespan
  • Health History
  • Communication Skills
  • Physical Assessment
  • Documentation
  • Differential Diagnosis

15
History
  • Collect interpret data related to the health
    history, chief complaint history of the present
    illness
  • Comprehensive history essential for establishing
    diagnosis (at least 80 of the time)

16
Communication Skills
  • Analyze communication methods for obtaining the
    health history
  • Effective communication styles interview
    techniques important elements for obtaining
    historical data setting tone for therapeutic
    relationships

17
Physical Assessment
  • Differentiate between variations of normal
    abnormal assessment data
  • Differential Diagnosis distinguishing abnormal
    from normal findings in 3 major areas of
    assessment
  • History
  • Physical Exam
  • Laboratory Data Diagnostic Tests

18
Document Assessment Findings
  • Accurate, systematic documentation, using
    standardized formats
  • Promotes continuity of care follow-up
  • Clarifies communication referral requests
    amongst professionals,
  • Provides accurate records for medico legal
    purposes

19
Differential Diagnosis
  • Analyze interpret data gathered during physical
    assessment
  • Focus critical evaluation of assessment data
    utilizing standard criteria for differential
    diagnosis of common health problems. Physical
    assessments will be practiced in lab.

20
References
  • Lecture notes CD-ROM presentations
  • Required textbooks
  • Optional References
  • Library-Building suggestions
  • Web sites

21
Required Textbooks
  • Swartz, Mark H. (1998) The Textbook of Physical
    Diagnosis History and Physical Examination, 3rd
    Edition, Philadelphia W B Saunders (ISBN
    0-7261-7514-X)
  • Swartz, Mark H. (1998) Pocket Companion to
    Textbook of Physical Diagnosis, 3rd Edition,
    Philadelphia W B Saunders (ISBN 0-7216-7517-4)

22
Resources
  • Audiovisual resources available at WSU
  • Related links of interest
  • CD-ROM information

23
Grade
  • Health History 20
  • Audio-taped interview
  • Dictation
  • Written documentation

24
Grade
  • Pediatric /or Geriatric Assessment 20
  • Written documentation
  • History
  • Development - Function
  • Physical Assessment

25
Grade
  • Midterm Exam 25
  • Multiple choice
  • Scheduled, proctored

26
Grade
  • Scheduled Assignments 10
  • Each class
  • Quizzes
  • Extra videotapes
  • Focus on major subjects

27
Grade
  • Final Exam 25
  • Last week of class
  • Scheduled, proctored

28
Topical Outline
  • Content
  • Sequence

29
QuickView Course Calendar
  • Content
  • Sequence with dates
  • Assignment due dates

30
Course Calendar Detail
  • Lesson by number topic
  • References
  • Assignments

31
Major Assignments
  • Health History outline grade guide
  • Pediatric outline of focal points grade guide
  • Geriatric outline of focal points grade guide

32
Health History Documentation
  • Full, detailed history. The interview audio
    recording should not exceed 30 minutes the
    dictation should be limited to no more than 20
    minutes. A complete written documentation is to
    accompany the audio-tape, including a genogram
    and ecomap.

33
Health History Documentation
  • The small audiocassettes for pocket recorders are
    preferred for recordings when possible.
  • Exceeding the time limits late submission of
    the assignment are subject to grade deductions.

34
Pediatric Assessment
  • A written documentation of a full assessment.
  • Pediatric outlines in the syllabus may be
    followed, as a guideline.

35
Pediatric Assessment
  • Major areas include
  • History (genogram ecomap included)
  • Development
  • Measurements
  • Physical Assessment
  • Assessment interpretation health plan

36
Geriatric Assessment
  • A written documentation of a full assessment.
  • Geriatric outlines in the syllabus may be
    followed, as a guideline.

37
Geriatric Assessment
  • Major areas include
  • History
  • Adult Development
  • Functional Assessment
  • Physical Assessment
  • Assessment interpretation health plan

38
Questions?
  • Some questions can be answered by instructors at
    each class site
  • Feel free to contact me by phone, e-mail or on
    discussion board

39
Advanced Practice Nursing Role Change
  • A public relations image may be important in a
    different way
  • ARNPs become their own public relations agents
  • Clients may choose an ARNP as their health care
    provider

40
Advanced Practice Nursing Role Change
  • First impressions are significant factors
  • ARNPs may need to market their services

41
Communication Issues
  • Depersonalization of technology
  • Health care as a business
  • Patient confidence in ARNPs as health care
    providers
  • Changes in collegial relationships with other
    professionals

42
Use of Descriptive Terminology
  • Be specific in documentation communication with
    colleagues
  • Use specific anatomy physiology terms
  • Review anatomy as appropriate

43
Appearance
  • ARNPs may not be in traditional roles or
    uniforms
  • Attire needs to be neat, clean professional,
    fitting the clinical setting
  • Care, friendly attitudes remain important

44
Appearance
  • The professional image includes more than
    scrubs, including accessories, face, hands
    nails, shoes
  • Student jackets name tags are to be worn for
    clinical practicums

45
Assessment Data Obtained From
  • History
  • Physical Assessment
  • Laboratory other diagnostic tests

46
The SOAP Format
  • A method of organizing assessment date
    treatment plan
  • A standard summary format

47
S - Subjective
  • Symptoms that the patient reports
  • What the patient feels
  • The history

48
O - Objective
  • Signs that can be observed by the examiner
  • Physical examination findings
  • Laboratory data other diagnostic tests

49
A - Assessment
  • Interpretation evaluation of data
  • Differential diagnosis
  • Medical diagnosis
  • Problem list
  • Needs to correlate with an insurance code

50
P - Plan
  • Diagnostic studies
  • Therapeutic regimen
  • Patient education

51
Goals/Purpose of Health History Interview
  • Establish a therapeutic relationship
  • Gather pertinent information
  • Evaluate the dynamics
  • Formulate a treatment plan

52
Significant Points for Establishing Rapport
  • Attitude friendly, relaxed, attentive
    interested
  • Respectfulness concern, compassion,
    confidentiality awareness of patient comfort

53
Significant Points for Establishing Rapport
  • Listening listen more, talk less, interrupt less
    focus on patients agenda (permit telling
    their story)
  • Nonjudgmental attitude about values, beliefs
    behaviors

54
Significant Points for Establishing Rapport
  • Matter-of-fact attitude that conveysyou can
    listen to human problems
  • Environment quiet, private, comfortable

55
General Approaches
  • Begin with open-ended questions
  • Follow-up with direct questions for more specific
    information, as in ROS
  • How come? or In what way? questions are
    easier to answer than Why? questions
  • Introduce easiest subjects first, before
    sensitive or painful issues

56
General Approaches
  • Avoid leading questions, which suggest a
    desired or expected answer
  • Avoid questions leading to yes or no response
    (grade responses yield more information)
  • Keep note-taking to essentials during the
    interview

57
Nonverbal Communication
  • Active listening includes eye contact
    attentive posture
  • Cultural orientation can be a guideline for
    interpersonal distance
  • More than 5 feet impersonal space
  • Less than 3 feet private space

58
Hindrances for Interviewer
  • Fatigue
  • Anxiety
  • Bias
  • Personal problems

59
Interview Stages
  • Introductory establish rapport define
    expectations
  • Working develop diagnostic hypothesis shared
    understanding of the problem
  • Termination negotiate a plan close the
    interview

60
Approaches to the Interview
  • Facilitation - encourage patient to say more
  • Reflection - repeat patients words to encourage
    more detail
  • Clarification - request or restate to clarify
    meaning
  • Summarization - clarify or interpret what has
    been said

61
Approaches to the Interview
  • Validation - recognize patients feelings, or
    experience
  • Empathy - identify with patients feelings
  • Support - premature reassurance can block
    communication
  • Transitions - organize the flow or control
    rambling

62
Avoid Roadblocks
  • Reassuring cliches, or stereotyped comments
    (false reassurance)
  • Advice, especially if premature
  • Approval/agreement or disapproval/disagreement
  • Leading questions multiple questions

63
Avoid Roadblocks
  • Interpreting
  • Belittling or minimizing feelings or situations
  • Acting defensively
  • Abruptly changing the subject

64
Examples of Sensitive Topics
  • Bias cultural differences
  • Alcohol drugs
  • Sexual history
  • Domestic violence
  • Mental illness
  • Death dying
  • Sexuality in clinician - client relationship

65
Special Situations
  • Use of silence
  • The talkative patient
  • Patients with multiple symptoms
  • Anxious patients
  • Intoxicated patient
  • Crying

66
Special Situations
  • Confusing behaviors or histories
  • Patients with limited intelligence
  • Limited or no ability to read
  • Language barriers
  • Working with an Interpreter

67
Special Situations
  • Patients with sensory deficits (hearing, vision)
  • Talking with families or friends

68
Health History Format
69
Biographical Data
  • Name, age, gender, family/marital status,
    religion, ethnic group
  • Date, address, occupation, HEALTH INSURANCE
  • Referral source, informant (reliability)
    (document)

70
Chief Complaint
  • Purpose of visit
  • Brief, 1-2 symptoms duration
  • Pertinent

71
Present Illness (Problem) or Current Health
Status
  • PI Illness or focused history
  • Initial wellness history
  • Interval history

72
PI Analysis of a Symptom
  • Onset
  • Characteristics
  • Course since onset
  • Pertinent negative information

73
PI Analysis of a Symptom
  • When Last well Onset, duration chronological
    sequence of symptoms
  • What Quality, intensity, related symptoms
  • Where Location, range of symptoms

74
PI Analysis of a Symptom
  • How Associated factors, communicable exposure
  • Why Possible solutions, treatment,
    (aggravating/alleviating factors)

75
Alternative Methods for Present Illness PI
76
PI Bates
  • Location
  • Quality
  • Quantity or severity
  • Timing (onset, duration, frequency)
  • Setting in which symptoms occur

77
PI Bates
  • Factors that aggravate or relieve
  • Associated manifestations
  • Significant negatives (absence of symptoms that
    aid in differential diagnosis)

78
PI OLD CART
  • O - Onset
  • L - Location
  • D - Duration
  • C - Causative factors
  • A - Associations
  • R - Reactions to what has been tried
  • T - Treatment

79
Past Medical History
  • General health strength
  • Major childhood adult illnesses
  • Immunizations, dates reactions
  • Surgery dates, hospital, Dx, complications
  • Injuries
  • Disability
  • Medial-legal relationships

80
Past Medical History
  • Medications current, past, Rx, OTC, herbs,
    alternative therapies
  • Allergies medication, environment, food must
    include kind of reaction
  • Transfusions reactions, date of units
  • Emotional status mood disorders, psychiatric
    attention

81
Family History
  • Family members with patients illness
  • Age of parents age cause of death
  • Age of siblings health status
  • History of heart disease, hypertension, cancer,
    TB, diabetes, asthma, STDs, kidney, thyroid
    disease, psychiatric illness
  • Major genetic disorders health problems

82
Family History
  • Genogram to grandparents

83
Personal Psychosocial History
  • Personal status birthplace, socioeconomic group,
    general life satisfaction, interests, sources of
    stress
  • Habits diet, sleep, exercise, coffee, alcohol,
    drugs, tobacco
  • Sexual History satisfaction. Concerns

84
Personal Psychosocial History
  • Home conditions housing, economic conditions,
    safety
  • Occupation work conditions or hazards
  • Environment Travel, milk water supply
  • Military record dates geographic travel
  • Religious preference concerns health care

85
Review of Systems ROS
  • Variations with age groups
  • General fever, chills, sweats, weight changes,
    weakness, fatigue, heat/cold intolerance,
    bleeding, radiation

86
ROS Skin, Hair, Nails
  • Rashes, lumps, sores, itching, color or texture
    changes, bruising, abnormal growths

87
ROS Head
  • Headaches, injury, dizziness, syncope, LOC, stroke

88
ROS Eyes
  • Vision/correction, blurring, diplopia, eye meds,
    trauma, redness, pain, glaucoma, cataracts,
    surgery

89
ROS Ears
  • Hearing/loss, pain, discharge, infection,
    tinnitus, vertigo, dizziness

90
ROS Nose
  • Smell, obstruction, injury, epistaxis, discharge,
    colds, allergies, sinus pain

91
ROS Mouth Throat
  • Hoarseness, sore throats, gum problems, tooth
    abscess, dental care, sore tongue, taste

92
ROS Neck
  • Lumps, swollen glands, goiter, pain, stiffness

93
ROS Respiratory
  • Pain, dyspnea, SOB, cyanosis, wheezing, cough,
    sputum (color quantity), asthma, bronchitis,
    emphysema, pneumonia, TB/BCG, last CXR
    results, smoking

94
ROS Cardiovascular
  • Chest pain/distress, palpitations, SOB, dyspnea,
    orthopnea (pillows needed), paroxsysmal nocturnal
    dyspnea, MI, rheumatic fever, murmur, exercise
    tolerance, ECG or other cardiac tests,
    hypertension, edema, leg pains/edema/coolness/hair
    loss, varicose veins, thrombosis ulcers

95
ROS Gastrointestinal
  • Appetite, digestion intolerance, heartburn, N
    V, hematomesis, bowel irregularity, stool
    appearance, flatulence/belching, hemorrhoids,
    jaundice, ulcer, gallstones, abdominal
    enlargement, previous X-ray

96
ROS Endocrine
  • Thyroid enlargement/tenderness, heat/cold
    intolerance, unexplained weight change, diabetes
    S/S, striae

97
ROS Male Reproductive
  • Puberty onset, erections, emissions, testicular
    pain or masses, hernias, lesions/discharges,
    libido, sexual activity, contraception,
    infertility, prostate, STDs, STE

98
ROS Female Reproductive
  • Menses Menarche, regularity, duration amount
    of flow, dysmenorrhea, LMP, last Pap AND RESULTS,
    sexual activity, libido, contraception,
    fertility, menopause, discharge, itching, sores,
    STDs
  • Gravida/para SAB, TAB, pregnancies, duration,
    births, problems

99
ROS Breast
  • Pain, tenderness, discharge, lumps, galactorrhea,
    mammogram AND RESULTS, SBE

100
ROS Genitourinary
  • Dysuria, pain, frequency, urgency, nocturia,
    hematuria, stress incontinence, hernias, STDs

101
ROS Musculoskeletal
  • Joint stiffness, pain, motion restriction,
    weakness, paresthesias, cramps, deformities, back
    problems

102
ROS Hematologic
  • Anemia, lymph swelling, bruising/petichiae,
    fatigue, blood dyscrasia, transfusion, radiation

103
ROS Neurologic
  • CNS disease, syncope, blackouts, dizziness,
    numbness, tingling, seizures, weakness/paralysis,
    tremors, coordination, memory, cognition,
    headaches, head injury

104
ROS Psychiatric
  • Depression, mood changes, difficulty
    concentrating, nervousness, tension, suicidal
    thoughts, irritability, sleep disturbances

105
Concluding Questions
  • Is there anything else that you think would be
    important for me to know?
  • Offer the opportunity for additions or
    corrections
  • Clarification of understanding

106
Analysis of Data
  • Identify abnormal findings
  • Cluster findings into logical groups
  • Localize findings anatomically

107
Analysis of Data
  • Localize findings into probable process
  • Pathological - such as inflammatory, metabolic,
    degenerative
  • Pathophysiological - mal functioning, such as
    congestive heart failure
  • Psychopathological - behavioral, mood disorder,
    though process disturbance

108
Analysis of Data
  • Construct a working hypothesis from the central
    findings
  • Match the findings with all causative conditions
    you know could be associated
  • Eliminate hypothesis that fail to explain the
    findings

109
Analysis of Data
  • Weigh the probabilities select the most likely
    diagnosis
  • Consider life-threatening treatable situations
  • Test the hypothesis or obtain further studies
  • Establish a working definition of the problem

110
Consider Information Quality
  • Reliability - how well an observation repeatedly
    give the same result
  • Validity - a close agreement between an
    observation the best possible measure of
    reality
  • Sensitivity - the proportion of people with a
    disease/condition who are positive for that
    disease on a given test (true positive)

111
Consider Information Quality
  • Specificity - the proportion of people without
    the disease/condition who are negative on a given
    test (true negative)
  • Predictive Value of Test - the characteristic
    that is most relevant to the clinical setting

112
Documentation of Data
  • Permanent medical legal record of the patients
    health status treatment
  • Record pertinent positive findings - abnormal
    findings
  • Record pertinent negative findings - normal
    findings, or absence of abnormal findings

113
Physical Examination
  • Inspection
  • Palpation
  • Percussion
  • Auscultation
  • Measurements

114
Inspection
  • Observe for wellness-illness condition
  • Identify degree of distress
  • Look before you touch
  • Provide comfortable, private conditions
  • Provide adequate direct tangential lighting

115
Palpation
  • Light palpation - gentle pressure, 1cm or 1/2 -
    3/4 inches deep
  • Deep palpation - may use bimanual methods, 4 cm
    or 1/5 - 2 inches deep
  • Palpate tender areas last

116
Palpation
  • Sensitive areas of hand fingers
  • Palmar area - discriminatory for touch
  • Ulnar area - discriminatory for touch
  • Dorsal area - discriminatory for temperature

117
Percussion Sounds Heard
  • Tympany
  • Hyperresonance
  • Resonance
  • Dullness
  • Flattness
  • Gastric bubble
  • Emphysema of lung
  • Healthy lung
  • Liver
  • Muscle

118
Auscultation
  • Listening to sounds of lungs, heart, blood
    vessels abdominal viscera
  • Ear
  • Stethoscope
  • Diaphragm is held firmly to skin, detects high
    frequency sounds
  • Bell is held with light pressure, detects low
    frequency sounds

119
Anthropometric Measurements Vital Signs
  • Height
  • Weight
  • Circumferences Head, Chest Abdomen, Extremities
  • Temperature, Pulse, Respiration, Blood Pressure
  • Vision Hearing Screening

120
Anthropometric Measurements Vital Signs
  • Jugular Venous Distention
  • Body Mass Index
  • Skin fold thickness
  • Goniometer measurements of joint mobility
  • Waist to hip ratio
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